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Process mapping evaluation of medication reconciliation in academic teaching hospitals: a critical step in quality improvement
  1. Anne Holbrook1,2,3,
  2. James M Bowen4,5,
  3. Harsit Patel6,
  4. Chris O'Brien6,
  5. John J You2,4,6,
  6. Roshan Tahavori7,
  7. Jeff Doleweerd8,
  8. Tim Berezny8,
  9. Dan Perri1,2,5,
  10. Carmine Nieuwstraten5,
  11. Sue Troyan7,
  12. Ameen Patel2,6
  1. 1Division of Clinical Pharmacology & Toxicology, McMaster University, Hamilton, Ontario, Canada
  2. 2Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  3. 3St Joseph's Healthcare & Hamilton Health Sciences, Hamilton, Ontario, Canada
  4. 4Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
  5. 5St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
  6. 6Hamilton Health Sciences, Hamilton, Ontario, Canada
  7. 7Clinical Pharmacology & Toxicology, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
  8. 8Doleweerd Consulting Inc., Orillia, Ontario, Canada
  1. Correspondence to Dr Anne Holbrook; holbrook{at}mcmaster.ca

Abstract

Background Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness.

Methods Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions.

Results Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses.

Discussion MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.

  • QUALITATIVE RESEARCH
  • INTERNAL MEDICINE
  • CLINICAL PHARMACOLOGY

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • Contributors AH led the conception of this study and acquisition of funding, participated in acquisition and analysis of data, and developed the final manuscript. JMB assisted with the design of the study, analysis and interpretation of the data and revision of the manuscript. HP, CO, JJY, DP, CN and AP assisted with the design of the study, acquisition and interpretation of data, and revision of the manuscript. RT assisted with the analysis and interpretation of the data and drafting and revision of the manuscript. JD and TB led the design of the study, acquisition of data, and assisted with developing of the manuscript. ST assisted with the design of the study, acquisition of the data and revision of the manuscript.

  • Funding Ontario Ministry of Health and Long Term Care Academic Health Sciences AFP Innovation Grant (Award number HAH-13-007).

  • Competing interests JD and TB are employees of a private consulting company hired to carry out the process mapping.

  • Ethics approval The study was approved by the Hamilton Integrated Research Ethics Board (Application numbers 13-841 and 13-842).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional data are available by emailing AH at holbrook@mcmaster.ca.

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